(2) The form, format, and delivery
of data elements reported and definitions will conform to the standards adopted
under section (1), unless otherwise provided in these rules.

(3) Copies of the guides in
section (1) are available for review during regular business hours at the Workers’
Compensation Division, Operations Section, 350 Winter Street NE, Salem OR 97301,
503-947-7742.

(a) IAIABC members may view
a copy of the Release 2.0 guide, or non-members may purchase a copy at the IAIABC
website: http://www.iaiabc.org.

(b) The ASC X12 999 guide is
available for purchase at the X12 online store: http://store.x12.org/store/healthcare-5010-consolidated-guides.

(9) “FEIN” means
the federal employer identification number or other federal reporting number used
by the insurer, insured, or employer for federal tax reporting purposes.

(10) “Header record”
means the record that precedes each transmission for the purpose of identifying
a sender, the date and time of the transmission, and the transaction set within
the transmission.

(11) “Health Care Provider”
has the same meaning as “medical provider,” under OAR 436-010-0005(28).

(12) “IAIABC” means
the International Association of Industrial Accident Boards and Commissions, a professional
trade association comprised of state workers’ compensation regulators and
insurance representatives (www.iaiabc.org).

(13) “If Applicable/Available
with Item Accept if Invalid” means the data element must be sent if appropriate
for the item record. Even if the item record has an invalid value, the transaction
set or item record will not be rejected.

(14) “If Applicable/Available
with Item Reject if Invalid” means the data element must be sent if appropriate
for the item record. If the item record has an invalid value, then the transaction
set or item record will be rejected.

(1) Before testing can begin,
or the division can accept medical billing data, the trading partner must submit
a completed Medical Billing Data EDI Trading Partner Profile (Form 4015) to the
division’s EDI Coordinator. Form 4015 is available on the division’s
website: http://wcd.oregon.gov/operations/edi/ediindex.html#bill.

(2) For test purposes each transmission
must conform to the standards specified in OAR 436-160-0004.

(3) Test files will be evaluated
in terms of whether the data sent was received in the correct standardized format
and fully processed by the division’s information processing system.

(4) The EDI Coordinator will
determine the number of required transactions per test submission based on the anticipated
volume of production transactions.

(1) Insurers with an average of at least
100 accepted disabling claims per year, based on the average accepted disabling
claim volume for the previous three calendar years, are required to electronically
submit detailed medical bill payment data to the Department of Consumer and Business
Services under OAR 436-160-0415.

(2) The director will notify
an insurer when the insurer has reached a three-year average accepted disabling
claim count of at least 100. The insurer is required to report medical bill payment
data beginning with the date specified in the notice and must continue to report
in subsequent years.

(3) If the insurer’s claim
count drops below an average of 50 accepted disabling claims, based on the average
accepted disabling claim volume for the previous three calendar years, insurers
may apply to the director for an exemption from the reporting requirement.

(4) The list of insurers required
to report medical bill data is published in Bulletin 359.

(5) Insurers that do not meet
the requirement to submit medical data under (1) of this rule may voluntarily submit
medical billing data.

(1) The transmission data and format requirements
are included in the IAIABC EDI Implementation Guide for Medical Bill Payment Records,
Release 2.0, dated Feb 1, 2013, and Appendices A and B of these rules. Oregon-specific
information can be found on the division’s Electronic Data EDI webpage: http://www.cbs.state.or.us/wcd/operations/edi/ediindex.html.

(a) Medical bills, including
interpreter bills under OAR 436-009, must be reported within 60 days of the date
paid.

(b) Denied medical bills for
accepted claims must be reported within 60 days of date of denial. Denied bills
are defined as any bills in which there is a non-zero charge and a zero payment.

(c) Transactions must be received
and accepted by the division within 60 days of either the date paid or the date
denied to be considered timely reported. If a transaction is initially rejected
it must be corrected, resubmitted, and accepted within the original 60 day time
period to be considered timely reported.

(d) Cancellations must be reported
as soon as the payer knows that a medical bill was sent in error.

(e) Corrections/Replacements
must be reported within 60 days of changes to any of the “Fatal Technical,”
“Mandatory,” or “Mandatory Conditional” data elements in
Appendices A and B.

(f) Bills received by the insurer
before July 1, 2014, may be reported to the Division using the IAIABC reporting
standard version 1.1.

(2) Data reporting requirements
are described in Appendices A and B.

(3) Technical requirements are
described on the division’s Electronic Data EDI webpage for specifications
on the Secure File Transfer Protocol (SFTP) requirements.

(4) Data Quality: The director
will conduct electronic edits for blank or invalid data. Affected insurers are responsible
for pre-screening the data they submit to check that all the required information
is reported and is formatted correctly. OAR 436-160-0420 describes the acceptance
or rejection protocol for all reported medical bills. The insurer is responsible
for timely correcting and resubmitting all rejected transactions for which law or
rule require filing, reporting, or notice to the director.

(5) An insurer must request
and receive authorization from the director to stop submitting a previously rejected
transaction when the division determines the transaction is uncorrectable.

(6) The director will periodically
review reported bill data to monitor insurer performance. If the director finds
repeated or egregious violations of the reporting requirements of these rules the
director may issue civil penalties under OAR 436-160-0445 and ORS 656.745.

(a) Medical bills must be reported
timely. “Timely” means that an insurer reports medical bills as required
by OAR 436-160-0415(1).

(b) Medical bills must be reported
accurately. “Accurately” means that the reported medical bill data accepted
by the division conforms to the reporting requirements of the Appendices A and B.

(c) The insurer may be subject
to penalties for any reported medical bills that have not been accepted by the division
or designated as uncorrectable under OAR 436-160-0415(5) within 180 days of the
date of bill payment or denial.

(1)(a) The sender is expected to retrieve
both TA1 and 999 interchange and functional acknowledgements (as defined by ASC
X12) for each medical bill batch submitted, unless technical errors in the file
prevent 999 processing. In addition, the sender is expected to retrieve the 824
detailed acknowledgement (as defined by IAIABC Release 2.0) for each medical bill
batch submitted, if the batch has successfully passed the 999 edits.

(b) The detailed acknowledgement
will indicate either an item accepted (IA) or an item rejected (IR) acknowledgement
for each individual transaction.

(2) A TA1, 999 or 824 acknowledgement
will be available for all transactions the division is unable to process, including
but not limited to:

(a) An omitted mandatory data
element;

(b) An improperly populated
data element field, e.g., numeric data element field is populated with alpha or
alphanumeric data, or is not a valid value according to the standards adopted in
436-160-0004;

(c) Transactions or electronic
records within the transaction that require matching, and cannot be matched to the
division’s database, e.g., cancellation of an original bill that does not
match the Unique Bill ID;

(3) A transaction accepted acknowledgement
will be available for all transactions that are in a format capable of being processed
by the division’s information processing system and that are not rejected
under section (2) of this rule.

(4) An insurer’s obligation
to report medical bill data for the purposes of this rule is not satisfied unless
the division acknowledges acceptance of the transaction.

(1) Under ORS 656.745, the director may
assess a civil penalty against an insurer that fails to comply with ORS chapter
656 or the director’s rules and orders.

(2) The insurer is responsible
for its own actions as well as the actions of others acting on the insurer’s
behalf. If an insurer or someone acting on the insurer’s behalf violates any
provisions of these rules, the director may impose a civil penalty against the insurer.

Notes1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2012.